Conference Materials

REGISTRATION INFORMATION REGISTRATION FEES REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. CONTINUING EDUCATION More Information Coming Soon! HOTEL RESERVATIONS The Swissôtel has set aside special group rates for conference attendees. The Swissôtel 323 East Wacker Drive, Chicago, IL 60601 (312) 565-0565 Group Room Rates: $319 Single/Double Group Room Block Name: 16th Annual Spine, Orthopedic & Pain Management To make your reservation online, follow this link: https://book.passkey.com/ event/49778607/owner/1461/home CONFERENCE QUESTIONS For additional information regarding the conference, exhibiting or sponsoring please contact: Becker's Healthcare Phone: 800.417.2035 Fax: 866.678.5755 Email: events@beckershealthcare.com ADA REQUEST If you require special ADA accommodations, please contact us at 800.417.2035. ONLINE REGISTRATION www.regonline. com/17thspineorthoasc TO REGISTER: Call 800.417.2035 • Fax 866.678.5755 • Email registration@beckershealthcare.com COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Online: www.regonline.com/17thspineorthoasc Fax: Fax registration form with credit card information to 866.678.5755 Call: Call 800.417.2035 to register by phone Email: registration@beckershealthcare.com Cancellation Policy: Written cancellation requests must be received within 120 days of transaction or by May 1, 2019, whichever is first. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. Multi-Attendee Discount Policy: To be eligible for the discount, your ASC must be registered at one time and work at the same address. Just copy the registration form for each attendee. Employees from a 2nd location are not eligible for the discount. 1 7 TH ANNUAL FUTURE OF SPINE + THE SPINE, ORTHOPEDIC & PAIN MANAGEMENT-DRIVEN ASC CONFERENCE THE 17TH ANNUAL CONFERENCE FROM ASC COMMUNIC ATIONS JUNE 13 -15, 2019 • SWISSOTEL • CHIC AGO, ILLINOIS ANNUAL CONFERENCE & EXHIBITS – Receive multiple registrant discount(s). The more people you send, the greater discount you receive. The prices listed below are per person. Your registration includes all conference sessions, materials and the networking functions. MAIN CONFERENCE + PRE-CONFERENCE FEES AMOUNT FEES AMOUNT (Before 5/1/19) (After 5/1/19) 1st Attendee $800 $ __________________ $900 $ _______________ 2nd Attendee $775 $ __________________ $875 $ _______________ 3rd Attendee $750 $ __________________ $850 $ _______________ 4th Attendee or more $725 $ __________________________ $825 $ _______________ Add $100 to subscribe to Becker's ASC Review or Becker's Spine Review (+$100) TOTAL ENCLOSED $________________________________ c I authorize to charge my: c c c Credit Card Number: __________________________________ Expiration Date: _____________________ Printed Cardholder Name: _____________________________ Zip Code: ___________________________ Cardholder Billing Address: ___________________________ City/State/Zip:_______________________ Signature: ______________________________________________ CVV#/3-digit #:______________________ First/Last Name: ________________________________________________________________________________________ Designations (As you wish it to appear on your badge): ________________________________________________ Title: ___________________________________________________________________________________________________ Facility/Company: _____________________________________________________________________________________ Address: _______________________________________________________________________________________________ City/State/Zip: _________________________________________________________________________________________ Phone:__________________________________ Fax: ________________________________________________________ Email:__________________________________________________________________________________________________ GENERAL INFORMATION TO REGISTER PAYMENT INFORMATION

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